Instruction Script

Data Collection Choreography

Clinic Staff Sample Introduction

Today we have staff from NORC at the University of Chicago asking clinic users who are waiting to be seen to participate in a confidential survey sponsored by the Centers for Disease Control, also known as the CDC, about their reasons for visiting this clinic. The survey is very brief and you make choose if you want to participate or not. The staff member will be in the waiting room/[insert designated area] and will answer any questions you have.

NORC Staff Introduction

Hello, my name is _____________ with NORC at the University of Chicago. I am here to ask clinic users to participate in a brief survey that is part of a research study being sponsored by the Centers for Disease Control and Prevention, also known as the CDC. The survey asks about your reasons for choosing this clinic and where else you could get health care if this clinic did not exist. The survey is completely anonymous and confidential. We will not collect any information that will identify you, such as your name, and your survey will be placed directly in this envelope when you are done. It should take about 10 minutes to complete and we would like you to complete the survey while you are waiting to be seen. Do you have any questions about the survey?

[IF RESPONDENT APPEARS TO BE 18 OR YOUNGER] Just to be sure, are you 13 years of age or older?

[IF NO] This research study is limited to adults and children aged 13 or older, thank you for your time.

[IF YES, CONTINUE]

Will you participate in this important research study by completing this short survey?

[IF NO] Attempt to find out why they are refusing and address their concern(s).

[IF YES, CONTINUE]

Consent

Thank you for agreeing to participate. I have this form here that I would like you to read over. It explains the study and your rights as a participant. Please take a moment to read it over, and later I will ask if you have any questions.

[ALLOW RESPONDENT TO READ CONSENT]

Do you have any questions?

[ADDRESS QUESTIONS]

Do you consent to participate in this research study?

[IF NO] Attempt to address concern(s).

[IF YES, CONTINUE]

Questionnaire Completion

Thank you. Here is the survey, please complete it and bring it back to me when you are finished.

Post Completion Steps

When the respondent returns the survey, ask them to double-check that they answered all of the questions on the front and the back of the survey. Tell them to put their survey into the appropriate folder based upon what you believe their gender to be.

End of Day

After a shift of collecting questionnaires, apply labels to each questionnaire in the box on the back. Use the “M” labels for all of the questionnaires in the male folder and the “F” labels for all of the questionnaires in the female folder. Do not look at the answers on the questionnaires to determine what gender a person was or what label to use.